Tobacco use is said to be higher among those with mental illness compared to the general population. In the United States of America, it has been estimated that 35% of cigarette smokers have a mental health condition, and account for 38% of all U.S adult cigarette use.1 A study conducted among adults with mental illness in the Eastern Cape, South Africa revealed a high prevalence of lifetime and current tobacco use of 54.9% and 44.6%, respectively.2 Du Plooy and colleagues’ study among a sample of 160 inpatients from the Stikland Hospital Acute Male Admission Unit in Cape Town revealed that 91.4% were current smokers of whom 82% smoked daily.3 Notably, tobacco use has been estimated to be particularly higher among those who are diagnosed with mood disorders, anxiety disorders, substance disorders, psychosis, and developmental disorders.4 For instance, Tindimwebwa and colleagues reported a high prevalence of lifetime tobacco use among individuals with schizophrenia (67.9%) and cannabis-induced disorders (97.3%).2 Additionally, previous research has reported that people with mental health conditions die almost 15 years earlier than those without mental disorders, who do not smoke.4 A variety of theories have been proposed to explain the high rate of tobacco use among this vulnerable group. Previous investigators have found that tobacco companies encourage these high smoking rates among the mentally ill using specific tactics such as funding psychiatric institutions and research supporting the “tobacco for self-medication” hypothesis.5 For these reasons, it is imperative to better understand the nature and extent of the tobacco industry’s influence on tobacco use among this population.
Subscribe to my newsletter here!
The tobacco industry employs multiple tactics to promote and market tobacco smoking to this population and, the internal tobacco industry documents reveal some of these tactics. Specifically, the internal tobacco industry documents provide insights into the industry motives, strategies, tactics, and data, including their marketing strategies to specific populations such as women, people in the military, LGBT, the homeless, African Americans, youth as well as those who are with mental health conditions.6 Nicotine has mood-altering effects that can temporarily mask the negative symptoms of the mental health condition, placing those with such conditions more vulnerable to smoking and nicotine addiction.4,7 Therefore, the tobacco industry has been said to push the narrative that smoking cigarettes is a form of self-medication through donating funds and funding research.8 Tobacco companies work with academic researchers and shape research questions as well as answers about the relationship between mental illness and smoking.9 The industry, therefore, propagate and foster the myth that the mentally ill need to smoke in order to manage symptoms and such people suffering from mental illness cannot stop smoking, or that quitting would be difficult as it would worsen their symptoms.7 Prior research has also reported that the industry manipulates data on the health impact of smoking among the mentally ill through publishing research supporting that individuals with mental illnesses are immune or are less susceptible to tobacco-related disease, despite compelling scientific evidence to the contrary.7
Numerous research and scientific evidence have emerged indicating that tobacco use places those with mental health conditions at a higher risk for respiratory, cardiovascular diseases, and lung cancer.7 Direct smoking and exposure to second-hand smoke have been linked to the development of generalized anxiety disorder, depression, conduct disorder, and attention deficit hyperactivity disorder (ADHD).2,8 In schizophrenic individuals, smokers experience increased psychiatric symptoms and are more likely to be hospitalized compared to those who do not smoke.7,8 Additionally, tobacco use reduces the effectiveness of certain medications for mental health.2,8 For example, drugs such as antidepressants are metabolized by hepatic cytochrome (CYP) 1A2 enzymes, and polycyclic aromatic hydrocarbons found in cigarettes induce enzymes in heavy-to-moderate smokers. This enzyme induction in turn impacts drug metabolism leading to lower therapeutic blood levels and the need for a higher dosage, consequently increasing the risk of adverse effects. Therefore, cessation can allow individuals on certain antipsychotic medications to reduce their dosage by 25%.4 Thus, cessation has been found to improve mental health through the reductions in depression, anxiety, and PTSD symptoms.8
Subscribe to my newsletter here!
The industry employed marketing strategies to promote the use of tobacco among the mentally ill. In advertisements, tobacco companies present smoking as a means of relaxation and stress relief.10 This theme can be seen in early advertisements, for example, an advert by Spud cigarette wrote “do you smoke away anxiety… then you’ll appreciate Spuds greater coolness” (Figure 1).11 Similarly, Camel cigarette brand advertisement showed a woman who seemed very sad, almost depressed in one frame, and this same woman in the next frame holding a cigarette smiling with a tag line “get a LIFT with a Camel” (Figure 2).12 Such evidence is largely limited to the early 1990s, however, currently social media and actors on television have been on the forefront in pushing this “self-medication” narrative about using tobacco. For example, Watson and colleagues explored young people’s perceptions of smoking in the media.13 Participants were shown audio-visual clips from movies and TV segments such as Titanic, My Best Friend’s Wedding, Independence Day, and Beautician and the Beast as well as The Simpsons. Such clips showed actors smoking and the participants were asked to rate and discuss their perceptions of these clips. The findings revealed that the participants perceived smoking in these media selections to be normal or acceptable and they identified smoking with stress-relief.13
Subscribe to my newsletter here!
Moreover, the tobacco industry promoted smoking and recruited new smokers in psychiatric settings or institutions by providing free samples of cigarettes and supporting efforts to block smoke-free psychiatric hospital policies.14 Giveaways were done merely for the purpose of increasing sales as well to develop a relationship with the recipient organization.15 As cited in Apollonio and Malone, evidence from the internal tobacco industry documents show conversations between tobacco companies and mental health hospital representatives.14 A letter was found from a mental health hospital representative asking for donations and in which it specifically stated:
“If you could, by some miracle, donate cigarettes or tobacco to the hospital to the patients it would be very much appreciated. As you know, it is very hard to stop smoking and for some here it is all they have. A majority of the patients here do not have family who are involved or care enough about them to bring cigarette to them”.16
Tobacco companies have been found to have relations with other organizations such as homeless shelters, drug treatment facilities, nursing homes, women and children shelters as well as convalescent care centers.5 Notably, all these organizations serve many people with mental health conditions and oftentimes facilitated the donation of cigarettes to their institutions by the tobacco companies. A conversation between an executive director of a women and children’s shelter and R.J. Reynolds Tobacco Company was found in the internal tobacco industry documents.14 The executive director asked for donations and specifically wrote the following:
“I am specifically asking if you might consider giving us cigarettes, factory rejects, or irregulars would be fine for clients. When clients come to our door they are usually depleted of all funds and resources. We do not believe this is most appropriate time to give up smoking, it simple add to their stress”.17
Mental illness institution and other organizations thought of the provision of cigarettes as caring for the patients. Therefore, many psychiatric institutions encouraged smoking and even provided cigarette to patients or outdoor smoke breaks as a reward for medication compliance and good behavior.5
The tobacco industry supported efforts to block smoke-free psychiatric hospitals policies.4 The Joint Commission on Accreditation of Healthcare Organizations mandated that all U.S. hospitals become smoke-free in the 1990s, but inpatient mental and drug abuse facilities were exempted due to patient and advocacy group protests. In 1994, mental illness advocacy groups such as the New York City National Alliance for the Mentally ill and the Friends and Advocates of the Mentally Ill (FAMI) protested in the beliefs of protecting the rights of patients to smoke in psychiatric hospitals in discrete smoking areas.18 In south Africa, despite the introduction of the Tobacco Products Control Act which bans smoking in indoor places; designated smoking areas, smoking in public places and public transport is permitted.19 Most health care facilities are not yet compliant and allow for smoking.3
Research has shown that people with mental health condition want to quit and are able to quit without impairing their mental health recovery.3,5 Quitting tobacco use has been associated with improved mental health.14 It is therefore important to have smoking cessation programmes that do not only target the general population but vulnerable groups like those suffering from mental illness as well due to the challenges they face and the tactics employed by the industry to ensure continuous tobacco use among this group.
Subscribe to my newsletter here!
Ms Zinhle Penelope Ngcobo is a Research Psychology Intern at the Alcohol, Tobacco, and Other Drug Research Unit (ATODRU) of the South Africa Medical Research Council (SAMRC). She obtained her bachelor’s and Honors degree in Psychology at the University of Kwa-Zulu Natal in 2017 and 2018 respectively. In 2022, she completed her Master’s in Social and Psychological Research at the University of the Witwatersrand, Johannesburg.
- American Lung Association. Behavioral Health and Tobacco Use. Accessed 11 May 2022, https://www.lung.org/quit-smoking/smoking-facts/impact-of-tobacco-use/behavioral-health-tobacco-use.
- Tindimwebwa LK, Ajayi AI, Adeniyi OV. Prevalence and determinants of tobacco use amongst South African adults with mental illness in the Eastern Cape. South African Journal of Psychiatry. 2021;27(1):1-9.
- Du Plooy J-L, Macharia M, Verster C. Cigarette smoking, nicotine dependence, and motivation to quit smoking in South African male psychiatric inpatients. BMC psychiatry. 2016;16(1):1-7.
- World Health Organisation. The vicious cycle of tobacco use and mental illness – a double burden on health. WHO. Accessed 12 May 2022, https://www.euro.who.int/en/health-topics/disease-prevention/tobacco/news/news/2021/11/the-vicious-cycle-of-tobacco-use-and-mental-illness-a-double-burden-on-health
- Scientific American. Smoking Is Way Down in the U.S., but Not for People with Mental Illness. Accessed 13 May 2022, https://blogs.scientificamerican.com/observations/smoking-is-way-down-in-the-u-s-but-not-for-people-with-mental-illness/
- University of California San Francisco Library. Marketing to Minorities, Military, and Gays MSA Collection. UCSF. Accessed 11 May 2022, https://www.industrydocuments.ucsf.edu/tobacco/collections/marketing-minorities-military-gays-msa-collection/
- Prochaska JJ, Hall SM, Bero LA. Tobacco use among individuals with schizophrenia: what role has the tobacco industry played? Schizophrenia bulletin. 2008;34(3):555-567.
- Prochaska JJ, Das S, Young-Wolff KC. Smoking, mental illness, and public health. Annual review of public health. 2017;38:165-185.
- Hirshbein L. Scientific research and corporate influence: smoking, mental illness, and the tobacco industry. Journal of the history of medicine and allied sciences. 2012;67(3):374-397.
- Truth Initiative. How tobacco companies linked cigarettes and mental health. Accessed 11 May 2022, https://truthinitiative.org/research-resources/targeted-communities/how-tobacco-companies-linked-cigarettes-and-mental-health
- National Public Radio. The Secret History Behind The Science Of Stress. NPR. Accessed 19 July 2022, https://www.npr.org/sections/health-shots/2014/07/07/325946892/the-secret-history-behind-the-science-of-stress
- Smithsonian Libraries. Camel Cigarette advertisement from 1934. Accessed 19 July 2022, https://library.si.edu/image-gallery/106550
- Watson N, Clarkson J, Donovan R, Giles‐Corti B. Filthy or fashionable? Young people’s perceptions of smoking in the media. Health Education Research. 2003;18(5):554-567.
- Apollonio DE, Malone RE. Marketing to the marginalised: tobacco industry targeting of the homeless and mentally ill. Tobacco control. 2005;14(6):409-415.
- Truth Tobacco Industry Documents. [Letter from RE Thornton to RM Murray regarding mental illness and DNA technology]. Accessed 7 June 2022, https://www.industrydocuments.ucsf.edu/docs/rnlw0192
- Truth Tobacco Industry Documents. WE ARE IN URGENT NEED FOR ASSISTANCE. Accessed 7 June 2022, https://www.industrydocuments.ucsf.edu/docs/fnvl0099
- Truth Tobacco Industry Documents. FOUR CORNERS HOUSE IS A FACILITY FOR HOUSING HOMELESS WOMEN AND CHILDREN. Accessed 7 June 2022, https://www.industrydocuments.ucsf.edu/docs/pgmn0061
- Truth Tobacco Industry Documents. MENTAL ILLNESS ADVOCACY GROUP BATTLING HOSPITAL SMOKING BAN IN NEW YORK. Accessed 7 June 2022, https://www.industrydocuments.ucsf.edu/docs/pjjk0067
- Tobacco Control Laws. Legislation by country: South Africa. Accessed 3 May 2022, https://www.tobaccocontrollaws.org/legislation/country/south-africa/summary